Revista Cuarzo (2019) volumen 25-1

P á g i n a | 16

REPORTE DE CASO

The VIP patient syndrome in Latin America is known as “The

recommended patient syndrome” a tale of unfortunate decisions
and complications.
Daniel Mauricio Núñez Campos1, Liliana Villamil Núñez2, Oscar Libardo Gómez Acevedo3, María Camila Peña
Pineda4.

Departamento de Emergencias. Residente de tercer año Medicina de Emergencias. Universidad del Rosario-Fundación Santa fe. Bogotá., Colombia.
1-2
3
Departamento de Emergencias. Residente de segundo año Medicina de Emergencias. Universidad del Rosario-Fundación Santa fe. Bogotá., Colombia.
4
Estudiante de Medicina. Universidad el Bosque. Bogotá, Colombia.

RESUMEN breaking standards of care and in the lowest scenario causing

Cuando un paciente tiene relación social, económica o familiar con
el equipo de salud que lo trata en el servicio de Urgencias existe un
riesgo sutil de tomar decisiones poco ortodoxas, además de usar
recursos de manera excesiva, romper protocolos de manejo y en el peor
de los escenarios causar complicaciones inesperadas al paciente. El
síndrome de paciente recomendado es una entidad descrita, consistente
en una serie de complicaciones médicas que involucran a un paciente
que ha ingresado a una institución y tiene un vínculo económico, social
o familiar con los médicos que lo atienden.
Reporte de Caso: reportamos el caso de una paciente de 55 años
familiar de un médico de urgencias quien ingresa a emergencias con
un cuadro de dolor abdominal, al ingreso se sospecha apendicitis
versus masa abdominal. Realizan tomografía abdominal contrastada, y
la paciente presenta una reacción alérgica al medio de contraste
requiriendo intubación orotraqueal la cual fue selectiva y llevo a una
atelectasia masiva. Después de la extubación presenta sobredosis por
fentanilo y finalmente estrés postraumático al egreso.
Conclusión: En Latinoamérica el síndrome de paciente recomendado
es una entidad que existe, esta poco descrita, en nuestro conocimiento
nunca ha sido cuantificada. Los pacientes son víctimas de múltiples
complicaciones no malintencionadas, que se originan en el deseo del
equipo médico de brindar una atención más cercana, rápida y
personalizada. Se puede prevenir fortaleciendo los principios éticos de
atención, realizando una historia clínica adecuada y un examen físico
detallado.
Palabras clave: recomendado, medio contraste / efecto adverso,
fentanilo/toxicidad, intubación /efecto adverso
unintended complications to the patient.
Case Report: We report a 55-year-old patient related to a physician.
She was admitted to the emergency room due to abdominal pain, on
admission was suspected appendicitis versus abdominal mass, an
abdominal CT scan with contrast was performed and she developed an
allergic reaction due to the contrast, she required intubation that was
complicated with selective intubation and a massive atelectasis. After
removal the orotracheal tube she presented fentanyl toxicity and finally
after discharge developed post-traumatic stress.
Conclusion: in LA (Latin America) this syndrome is an entity that
exists, has been little described and in our knowledge has never been
quantified. Patients are victims of multiple non-malicious
complications, which originate in the desire of their health team trying
to provide a closer, faster and more personalized attention outside of
the guidelines of treatment. Ethical principles and prevention should
be strengthened through an adequate clinical history and a detailed
physical examination to avoid this event.
Keywords: VIP syndrome, contrast media/adverse effect, fentanyl
toxicity, endotracheal intubation/adverse effects.
*Autor de correspondencia:
Daniel Mauricio Núñez Campos
daniel.nunez@urosario.edu.co
Como citar: Núñez Campos, DM, Villamil Núñez, L, Gómez Acevedo, OL, Peña Pineda
MC. The VIP patient syndrome in Latin America is known as “The recommended
patient syndrome” a tale of unfortunate decisions and complications. Revista Cuarzo
2019;25(1):16-20.

Recibido: 25 de noviembre de 2018

ABSTRACT Aceptado: 7 de febrero de 2019
Publicado: 30 de junio de 2019
The VIP patient syndrome in Latin America is known as DOI:https://doi.org/10.26752/cuarzo.v25.n1.391
“The recommended patient syndrome” a tale of
unfortunate decisions and complications.

When a VIP patient or a patient who has an economic, social or family

relationship with the doctors who treat them, arrive to the ER there is License creative
Commons
a subtle risk of making unorthodox decisions, Also, wasting resources,
The VIP patient syndrome in Latin America
I. INTRODUCTION
I
n Latin America there is scarcity of literature about the
syndrome known as “the recommended patient” defined as
the presence of unexpected or unusual complications in
patients that their health team are trying to give a better
assistance (1). In industrialized countries, it has been described
as a related phenomenon known as VIP syndrome, this was first
described in 1964 by Dr. Walter Weintraub at the Psychiatric
hospital where he defined what VIP syndrome means, he found
that the VIP patients were victims of the doctors who were
trapped in this syndrome (2).
II. CASE REPORT
A 55-year-old woman with a history of recurrent gastritis was
brought to the ER by his physician son for 8 hours of abdominal
pain in right lower quadrant, associated to fever, nausea and
four episodes of liquid stools. Vital signs were: blood pressure,
135/80 mmHg; heart rate, 95 beats/ minute; respiratory rate, 17
breaths/minute; oral temperature, 38,0˚C. At physical
examination she had a soft and non-distended abdomen, with
localized tenderness without guarding in the right lower
quadrant, and a palpable painless mass in hypogastrium. Blood
test results showed an elevated white blood cell count of
15,450u/L, hemoglobin 14,6g/dl and platelets 245mil/mm3
Twenty minutes after the injection of contrast for an abdominal
CT scan she developed, dyspnea, oppressive chest pain, and
cyanosis. Her saturation dropped to 60% at a FiO2 of 21%. She
was transferred immediately to a reanimation room and 2 L/min
oxygen was administered through a facial mask. Then, received
Figure 1: Chest-x-ray With Left Massive Atelectasis
Source: Courtesy from MCA.
is known… P á g i n a | 17
an injection of 1 mg of epinephrine and 200 mg of
hydrocortisone and 50 mg of ranitidine. However, she did not
improve, and she remained drowsy, about 10 minutes later she
went to endotracheal intubation with a rapid sequence of
intubation. She received 5 mg of midazolam (iv), 100 mcg of
fentanyl (iv) and 30 mg rocuronium (iv). However, her
saturation value did not improve, and her chest x-ray showed a
left pulmonary collapse with a selective right bronchial
intubation. Figure 1. The tube was relocated and five hours later
she was Weaning from the ventilator.
After removal the orotracheal tube the patient was alert.
However, during the following 3 hours, she became sleepy but
easily arousable. Also, bradipsychic, bradycardic and
hypotensive (Graphic 1). Suddenly, she developed horizontal
nystagmus, her pupils were miotic and had signs of respiratory
depression. Her airway was secured once again, and all the
monitors were checked. Her fentanyl infusion was running
since her first attempt of removal orotracheal tube. It was
suspected opioid toxidrome and 0,4mg of naloxone (iv) was
administered. After 1 minute she responded and improved her
neurological status. She was transferred to an intensive care
unit, where she recovered satisfactorily. She remains in the
wards during 7 days for an episode of acute diarrhea and no
tolerance to oral intake. Later recovery she was discharge with
no medications. At home, she experienced anxiety, insomnia
and nightmares with visualization of what happened. She was
diagnosed with post-traumatic stress syndrome and required
clonazepam for 3 months to control her symptoms. Finally, she
tapered the medication and did not required any other
intervention. Table 1.
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Núñez D et al.
Graphic 1: Vitals Sings of a Patient With Fentanyl Toxicity

Source: Data From e-health record.

Table 1: Past Medical History

PERSONAL HEALTH COMPLICATIONS BY CONDITIONS FOR BEING A VIP
IN FAVOR OF VIP PATIENT
HISTORY CLINICAL CONDITION PATIENT
Personal: Married, Catholic, 2
child’s, Professional Social No relationship Family doctor special treatment
Worker
Medical Conditions: Gastritis
None Attention by the son´s colleagues Unnecessary exams
(2004)
Overweight (2000) Difficult airway Attention by the son´s colleagues Fear to erring
abdominal wall eventration (2013) Difficulty abdominal palpation. Vigilance in resuscitation for your child No follow the rules
Allergies: None No relationship removal of endotracheal tube No follow the protocols
Medication: Esomeprazole 20
No relationship Infusion of fentanyl without control Inadequate communication
mg/day (2004)
Surgical history: C-section #1
Difficulty abdominal palpation Prolonged hospitalization Fear to erring
(1987) C-section (1989)
hysterectomy (2010),
Difficulty abdominal palpation
enterorrhaphy (2011)
Social: None No relationship
G/O: G2C2V2A0, Pomeroy, FUR
No relationship
2010.
Family: Mom: Sotmach CA, No relationship
Dad: Lung CA and allergic to
No relationship
contrast material (1997).

allergic to contrast material (1997) Genetic based

Source: Data From e-health record.

III. DISCUSSION
The recommended patient syndrome presents itself as a
series of medical complications that involve a patient who has
an economic, social or family relationship with the doctors who
treat him (1). In LA we found very few reports of this syndrome
(1,4). In our knowledge there is no data of the frequency of this
event in the emergency department even though, many people
have a relative, friend or acquaintance who works in the health
system and is susceptible of this occurrence.
Clinical manifestations
The VIP syndrome results when the process of care is not the
regular by cause of the relationship between the physician and
the patient. the unexpected complications are favored by a
chain of mistakes, that start with an incomplete medical record,
or perform the physical examination on inappropriate places or
do an excess of diagnostic procedures which ends on
unfortuitous complications.
Pathogeny
The medical decisions are made according to the findings found
in the anamnesis and in the physical examination; Many times,
the decisions are correct, however in this syndrome the final
decision take a different path because there are no adequate
conditions from the beginning of the encounter (4).
Sanz Rubiales et al suggest many causes for the appearance of
this syndrome in clinical practice: a) Patients preferences for a
prestigious physician. b) inadequate space and time for the
consultation c) incomplete clinical records. d) Incomplete or
excessive use of diagnostic tools. e) over treatment in a fashion
of “better is more than less” (1).
Ethical aspects:
In addition to the VIP syndrome, the emergency room, is one of
the first scenarios where the physicians have contact with VIP
patients, they are called that because of the acronym in English
that means "Very important people" who enjoy a social status
and/or economic that privileges them and makes use of it to
influence and modify the treatment they have in medical care
(5). In other words, the benefits of care are based on a reduction
of waiting time, personalized attention, special locations, care
by the head of the department, treatments and unnecessary
paraclinical (6). The VIP patient has 2 routes, the first one
where the patient demands their treatment preferences to the
institution, and the other, where the institution or the physician
is the one who inadvertently provides sumptuous and
preferential treatment, that in some cases ends with unfavorable
outcomes for the patient (7).
To continue Illen Dicker describes there is a pressure associated
with the care of these patients, close to 67% of the doctors
exposed to the treatment and management of a VIP patient, said
to feel an external pressure about the possible outcomes of their
patient, and does not act according to the medical logic, In
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addition to this feeling, the study reported that 56% of the
physicians agreed to the demands of the patients regardless of
whether they were relevant to their treatment (8). This is where
the ethical dilemma of the physicians begins, a struggle
between their autonomy and what is justly correct, a struggle
between what should be done and what the patient wants to be
done. This triggers a loss of clinical objectivity (9). Many times,
the physician´s desire to provide personalized and special
treatment to their patients creates a dispute between medical
autonomy and the principle of beneficence (10).
To avoid these mistakes, institutions and personnel in charge
for the care of VIP patients must provide professional care
based on ethical principles and science. Experts propose to
array a portfolio of services based on nine principles, these nine
principles can be summarized as follow: First, do not forget the
usual rules and roles, work as a team, communicate well with
the patient and your colleagues, manage media adequately,
medical care shouldn’t be borrowed by the boss, always address
conducts based on science and not on the patient's wishes,
ensure patient care, never accept gifts and work only with staff
of your institution and not with outsiders (11).
Our case 2: Our patient was admitted for abdominal pain,
fever and diarrhea. The most common cause of this symptoms
in our geographical area would be an acute diarrheal disease.
Because the patient was related to a physician, they wanted to
rule out a most serious pathology like appendicitis. The
subsequent difficulties were not caused directly by the
physicians. But nevertheless, the change of common practice
guidelines facilitated the occurrence of those unusual
complications.
IV. CONCLUSIONS
The VIP patient is the person who arrives at the health
institution and enjoys a higher status, whether due to social,
political, religious, economic or family ties with health
personnel. This link or quality creates personalized attention.
This is often reflected in unjustified and unnecessary exams and
treatments; this may trigger non-objective attention with the
appearance of inappropriate and biased behaviors, which cause
an unfavorable outcome. This is where the recommended
patient syndrome emerges. Yet until now there is no measured
direct determinant that links a clinical attribute of the patient or
his environment with the appearance of this syndrome. In
conclusion, its appearance could be caused by an antecedent or
direct clinical variable of the patient or by the special attention
to which it is exposed. Studies are needed to determine the final
etiology.
Written consent was obtained from the patient to use her
medical records and images in the publication of this
manuscript. The authors have no competing nor financial
interests.
Conflict of Interest: The authors declare no conflict of
 20 | P á g i n a Revista Cuarzo (2019) volumen 25-1
Núñez D et al.

interest.

REFERENCES

1. Sanz-Rubiales A, Del Valle-Rivero M, Flores-Pérez L,

Hernansanz S, García-Recio C, López-Lara M. El síndrome
del recomendado. An Med Int, 2002;19(8):430-433.
2. Weintraub W. The VIP syndrome: a clinical study in hospital
psychiatry. J Nerv Ment Dis 1964;(138):181–193.
3. Stelfox, H. The “To Err is Human” report and the patient
safety literature. Quality and Safety in Health Care.
2006;15(3):174–178.
4. Hernández M, Gea P, Medina L, Melgar García A, Sánchez
Pinilla M. Hipertensión arterial dentro del síndrome del
recomendado. Hipertensión 2002;19(7):327-328.
5. Mariano EC, McLeod JA. Emergency care for the VIP
patient. Intensive CareMedicine.New York, NY: Springer
New York; 2007. p. 969–75.
6. Diekema DS. The preferential treatment of VIPs in the
emergency department. Am JEmerg Med 1996;14(2):226–9.
7. Block AJ. Beware of the VIP syndrome. Chest
1993;104(4):989.
8. llen-Dicker J, Auerbach A, Herzig SJ. Perceived safety and
value of inpatient “veryimportant person” services. J Hosp
Med 2017;12(3):177–9.
9. ABIM Foundation. Medical professionalism in the new
millennium: aphysician charter. Ann Intern Med.
2002;136(3):243-246.
10. Alfandre D, Clever S, Farber N, Hughes M, Redstone P,
Lehmann L. Caring for ‘Very Important Patients’—Ethical
Dilemmas and Suggestions for Practical Management. The
American Journal of Medicine. 2016;129(2):143-147.
11. GUZMAN J, SASIDHAR M, STOLLER J. Caring for VIPs:
Nine principles. Cleveland Clinic Journal of Medicine.
2011;78(2):90-94.